Publications

Abstract

Changing practice is complex and multifaceted. I discuss an evidence-based change management model that can be applied to guide clinical practice improvement projects. I use NICHE as a case example. The overall success of any change initiatives relies on creating and following an action plan to address the “what of change” and the “how of change”. The “what of change” focuses on developing tailored interventions aligned with each nursing unit or service line strengths and opportunities to improve nursing care for older adults by implementing the four components of the NICHE practice model. The “how of change” focuses on the activities to prepare the environment to implement the NICHE practice model. Activities to manage the change process include how to effectively communicate a vision for change; mobilize managers, clinical leaders, and front-line staff to support the change in nursing practice; and tracking progress towards meeting clinical improvement goals over time.

Abstract

Background. Advancements in medical technology, healthcare delivery, and organ allocation resulted in improved patient/graft survival for older (age ≥65) kidney transplant (KT) recipients. However, the recent trends in these post-KT outcomes are uncertain in light of the mounting burden of cardiovascular disease, changing kidney allocation policies, heterogeneity in candidates' risk profile, and the coronavirus disease 2019 pandemic. Thus, we examined secular trends in post-KT outcomes among older and younger KT recipients over the last 3 decades. Methods. We identified 73 078 older and 378 800 younger adult (aged 18-64) recipients using Scientific Registry of Transplant Recipients (1990-2022). KTs were grouped into 6 prepandemic eras and 1 postpandemic-onset era. Kaplan-Meier and Cox proportional hazards models were used to examine temporal trends in post-KT mortality and death-censored graft failure. Results. From 1990 to 2022, a 19-fold increase in the proportion of older KT recipients was observed compared to a 2-fold increase in younger adults despite a slight decline in the absolute number of older recipients in 2020. The mortality risk for older recipients between 2015 and March 14, 2020, was 39% (adjusted hazard ratio [aHR] = 0.61, 95% confidence interval [CI], 0.50-0.75) lower compared to 1990-1994, whereas that for younger adults was 47% lower (aHR = 0.53, 95% CI, 0.48-0.59). However, mortality risk during the pandemic was 25% lower (aHR = 0.75, 95% CI, 0.61-0.93) in older adults and 37% lower in younger adults (aHR = 0.63, 95% CI, 0.56-0.70) relative to 1990-1994. For both populations, the risk of graft failure declined over time and was unaffected during the pandemic relative to the preceding period. Conclusions. The steady improvements in 5-y mortality and graft survival were disrupted during the pandemic, particularly among older adults. Specifically, mortality among older adults reflected rates seen 20 y prior.

Abstract

Chinese Americans comprise the largest Asian subgroup in the U.S. Yet, little research has focused on the well-being of this population. This study aimed to (1) examine psycho-physiological health (psychological stress and fatigue) and lifestyle behaviors (sleep and physical activity) between Chinese Americans and whites, and (2) investigate whether race and lifestyle behaviors were independent predictors of psycho-physiological health. This study included 87 middle-aged healthy adults (41 Chinese Americans, 46 whites). Each participant underwent a two-night actigraphy-based sleep assessment. Chinese Americans reported higher psychological stress and fatigue, had poorer objective sleep outcomes (shorter sleep duration, lower sleep efficiency, and longer sleep onset), and engaged in lower physical activity levels than whites. Race and poor perceived sleep quality were independently associated with high psychological stress and fatigue. The findings warrant further exploration of social and cultural determinants of health in this minority group to reduce health disparities.

Abstract

PurposeTo examine the association between intensive, longitudinal ecological momentary assessment (EMA) and self-reported eating behaviors.MethodsSecondary analysis of the EMPOWER study—a 12-month observational study that examined the microprocesses of relapse following intentional weight loss using smartphone-administered EMA—was conducted. Participants were asked to complete four types of EMA surveys using a mobile app. For this analysis, only the number of completed random EMA surveys was used. Using linear mixed-effects modeling, we analyzed whether the number of completed random EMA surveys was associated with changes in self-reported dietary restraint, dietary disinhibition, and susceptibility to hunger measured using the Three-Factor Eating Questionnaire (TFEQ).ResultsDuring the 12-month study, 132 participants completed a mean of 1062 random EMA surveys (range: 673–1362). The median time it took for participants to complete random EMA surveys was 20 s and 90% of random EMA surveys were completed within 46 s. The number of completed random EMA surveys was not significantly associated with the TFEQ scores.ConclusionsIntensive longitudinal EMA did not influence self-reported eating behaviors. The findings suggest that EMA can be used to frequently assess real-world eating behaviors with minimal concern about assessment reactivity. Nonetheless, care must be taken when designing EMA surveys—particularly when using self-reported outcome measures.

Abstract

Background: Analyses of factors that determine quality of perinatal care consistently rely on clinical markers, while failing to assess experiential outcomes. Understanding how model of care and birth setting influence experiences of respect, autonomy, and decision making, is essential for comprehensive assessment of quality. Methods: We examined responses (n = 1771) to an online cross-sectional national survey capturing experiences of perinatal care in the United States. We used validated patient-oriented measures and scales to assess four domains of experience: (1) decision-making, (2) respect, (3) mistreatment, and (4) time spent during visits. We categorized the provider type and birth setting into three groups: midwife at community birth, midwife at hospital-birth, and physician at hospital-birth. For each group, we used multivariate logistic regression, adjusted for demographic and clinical characteristics, to estimate the odds of experiential outcomes in all the four domains. Results: Compared to those cared for by physicians in hospitals, individuals cared for by midwives in community settings had more than five times the odds of experiencing higher autonomy (aOR: 5.22, 95% CI: 3.65–7.45), higher respect (aOR: 5.39, 95% CI: 3.72–7.82) and lower odds of mistreatment (aOR: 0.16, 95% CI: 0.10–0.26). We found significant differences across birth settings: participants cared for by midwives in the community settings had significantly better experiential outcomes than those in the hospital settings: high- autonomy (aOR: 2.97, 95% CI: 2.66–4.27), respect (aOR: 4.15, 95% CI: 2.81–6.14), mistreatment (aOR: 0.20, 95% CI: 0.11–0.34), time spent (aOR: 8.06, 95% CI: 4.26–15.28). Conclusion: Participants reported better experiential outcomes when cared for by midwives than by physicians. And for those receiving midwifery care, the quality of experiential outcomes was significantly higher in community settings than in hospital settings. Care settings matter and structures of hospital-based care may impair implementation of the person-centered midwifery care model.

Abstract

Massive rural-to-urban migration in China has a significant impact on informal caregiving arrangements among Chinese older adults. To stimulate research on the intersection of migration and caregiving, we conducted an inventory of longitudinal aging survey datasets from mainland China. Large publicly available datasets that included measures related to migration and caregiving were searched and reviewed for eligibility. Key characteristics of each dataset, including study design, sample size, and measures, were extracted. Seven eligible datasets were identified, and five included nationally representative samples. Measures for migration varied across datasets. Some datasets included information on the migration history of older adults, whereas others focused on the migration of adult children. Similarly, caregiving was measured using different questions in each dataset. Caregiving activities were assessed with regard to their type, source, and amount. High-quality datasets exist to support research on migration and caregiving arrangements among Chinese older adults.

Abstract

Objectives: It is well-established that racial discrimination influences quality of life, but there is scarce evidence about how racial discrimination affects oral health-related quality of life (OHRQoL). Furthermore, the pathways linking racial discrimination and OHRQoL remain unknown. Guided by the integrative framework of immigration, ageing, and oral health, psychosocial stressors and resources exert influences on OHRQoL. In addition, according to the compensatory model of resilience, resilient resources could counteract risk exposures to stressors given specific outcomes. Hence, this study examined the relationship between experiences of discrimination and OHRQoL and investigated resilience as a mediator in such a relationship among older Chinese immigrants. Methods: Data came from the Population Study of Chinese Elderly in Chicago collected between 2017 and 2019. The working sample included 3054 foreign-born older Chinese Americans aged 60 years or older. OHRQoL was measured by seven items from the Geriatric Oral Health Assessment Index. Experiences of discrimination (yes or no) were measured by the 9-item Experiences of Discrimination instrument. Resilience was measured by the 10-item Connor Davidson Resilience Scale. Mediation analysis was conducted to examine the direct and indirect pathways towards OHRQoL. Results: Experiences of discrimination were directly associated with poorer OHRQoL (b = −0.98, P <.05). Resilience partially mediated the relationship between discrimination experiences and OHRQoL. Specifically, discrimination experiences were associated with weaker resilience (b = −1.58, P <.05), and weaker resilience was associated with poorer OHRQoL (b = 0.06, P <.05). Conclusions: Findings illustrate the importance of studying racial discrimination and resilience in OHRQoL. Interventions need to consider individuals’ discrimination experiences and stress coping abilities to promote OHRQoL.

Abstract

Background: In recent years, stroke has become the second leading cause of death worldwide, and the incidence and mortality of ischemic stroke have increased significantly. This study mainly aimed to explore the experiences and needs of older adults at different stages of cerebral infarction based on the chronic illness trajectory theory. Methods: Data were collected from 22 older adults experiencing the onset, acute, and stable stages of stroke through semi-structured interviews and were analyzed using Colaizzi's descriptive phenomenological approach. Results: Multiple themes and subthemes emerged on the experiences and needs of older adults at different stages of cerebral infarction based on the three dimensions of the long-term disease trajectory theory: illness-related work, biographical work, and everyday life work. Seven themes were extracted for illness-related work, six for biographical work, and eight for everyday life work. Discussions: The treatment, nursing, and rehabilitation of cerebral infarction are complex. This study indicated that patients after cerebral infarction have different experiences and needs for illness-related work. They also have distinctive and dynamically changing demands for biographical work and everyday life work. Conclusions: The experiences and needs of older patients with cerebral infarction changed dynamically at different stages of the disease. Healthcare professionals should develop effective interventions targeting these needs at various disease stages, provide patients with continuous support to shape their disease trajectories, and maintain patients' stability.

Abstract

OBJECTIVES: To explore the correlation between health–illness transition (HIT) experiences and distress among patients with pancreatic cancer. SAMPLE & SETTING: 55 patients with a diagnosis of pancreatic cancer receiving chemotherapy at a tertiary cancer center in New York. METHODS & VARIABLES: A prospective correlational study was performed to explore the frequency, extent, and management of HITs. HITs were evaluated using the Measurement of Transitions in Cancer Scale, and distress was measured with the National Comprehensive Cancer Network Distress Thermometer. RESULTS: All patients experienced at least one HIT. The extent of HITs decreased over time. Patients reported that they managed HITs moderately well. There was a significant correlation between unmanaged HITs and distress. As distress increased, the extent of the physical and emotional HITs increased and management worsened. IMPLICATIONS FOR NURSING: HITs are ubiquitous among patients diagnosed with pancreatic cancer. Associated distress inhibits management. Nurses are well suited to assess for potential HITs and to support self-management of HITs.

Abstract

In this study, we examine how full nurse practitioner (NP) practice authority affects racial and ethnic diversity of the NP workforce. Specifically, the purpose of our research is to understand the relationship between the racial and ethnic composition of the NP workforce, NP level of practice authority, and the communities they service. In this paper, we compare the ethnic and racial composition of the NP workforce to the composition of the state's population, and then observe if there are any noticeable differences in the patients served by NPs when we compare full practice authority (FPA) and non-FPA states. We also estimate how FPA affects the race and ethnicity of Medicare patients served by NPs.

Abstract

Good oral health is essential for healthy aging. Regular dental care utilization is instrumental to good oral health. Older immigrants tend to experience poorer oral health and less dental care use as compared with their native-born counterparts in the host country. Older immigrants are particularly vulnerable to interrupted or lost social ties and acculturation challenges after immigration to a new country. This study examined whether and to what extent social relations, acculturation, and perceived oral health needs are associated with dental care utilization in foreign-born older Chinese Americans. Data came from the Population Study of Chinese Elderly in Chicago, which were collected between 2017 and 2019 (N = 3,000). Dental care utilization was dichotomized into “yes” versus “no” in the past 2 y. Social relations were measured by positive and negative relations with spouse, family, and friends. Acculturation was measured by length of stay, behavioral acculturation, and residence in Chinatown. Perceived oral health needs were measured by the presence of problems related to teeth, gums, or bleeding. As guided by the Andersen model, separate logistic regression models were used to investigate factors of dental care utilization. An overall 23.1% reported dental care utilization. Individuals with no negative relations with spouse, family, and friends were 31%, 36%, and 38% less likely to visit a dentist, respectively. Individuals with higher levels of behavioral acculturation were 4% more likely to visit a dentist; individuals living in Chinatown were 45% less likely; and individuals with perceived oral health needs were 2.5 times more likely. Findings illustrate the importance of understanding social relations, immigration-related factors, and perceived oral health needs in dental care utilization in older immigrants.

Abstract

Objectives This study aims to compare perceived family functioning between Chinese patients who had an acute ischaemic stroke (AIS) and family caregivers, and explore the association between family functioning and patients' depressive symptoms. Design This is a cross-sectional study design. Setting Stroke centres of two tertiary hospitals in Nanjing, China. Participants One hundred and sixty-nine dyads of patients who had an AIS and family caregivers. Primary and secondary outcome measures Family functioning of patients who had an AIS and their primary family caregivers was assessed by the Family Assessment Device (FAD, Chinese version). Depressive symptoms of patients who had an AIS was assessed by the Centre for Epidemiological Studies Depression Scale. We test the agreement and differences in family functioning. Multivariate linear regression models were used to test the association of differences of family functioning within dyads with patients' depressive symptoms. Results AIS families demonstrated unhealthy family functioning. A total of 115 patients (76.9%) and 124 caregivers (73.4%) had a score of 2 or higher in FAD-general functioning (GF), indicating unhealthy family functioning. The intraclass correlation coefficient of FAD subdomain between patients who had an AIS and caregivers ranged from 0.15 to 0.55, which indicating the agreement of family functioning within dyads was poor to moderate. There was a significant difference between the FAD-GF scores of the patients and those of their caregivers (Z=-2.631, p=0.009), with caregivers reporting poorer general family functioning. Poor family functioning and greater difference of perceived family functioning within dyads were related to higher level of patients' depressive symptoms (β=5.163, p<0.001, β=5.534, p<0.001, respectively). Conclusions These findings indicate that healthcare professionals should assess family functioning in both patients who had a stroke and caregivers. Improvement of family function and decreasing discrepancies within dyads may be helpful for relieving patients' depressive symptoms.

Abstract

Family members play a crucial role in the health of Asian American communities, and their involvement in health interventions can be pivotal in optimizing impact and implementation. To explore how family members can be effectively involved in Asian American health interventions and develop a conceptual framework of methods of involvement at the stages of intervention development, process, and evaluation, this scoping review documented the role of Asian American family members in interventions (across any health objective). Of the 7175 studies identified through database and manual searches, we included 48 studies in the final analysis. Many studies focused on Chinese (54%) or Vietnamese (21%) populations, were conducted in California (44%), and involved spouses (35%) or parents/children (39%). We observed involvement across 3 stages: (1) intervention development (formative research, review process, material development), (2) intervention process (recruitment, receiving the intervention together, receiving a parallel intervention, enlisting support to achieve goals, voluntary intervention support, agent of family-wide change, and participation gatekeepers), and (3) intervention evaluation (received evaluation together, indirect impact evaluation, and feedback during intervention). Impact of family member involvement was both positive (as sources of encouragement, insight, accountability, comfort, and passion) and negative (sources of hindrance, backlash, stigma, obligation, and negative influence). Suggestions for future research interventions include (1) exploring family involvement in South Asian or young adult interventions, (2) diversifying types of family members involved (eg, extended family), and (3) diversifying methods of involvement (eg, family members as implementation agents).

Abstract

Effective antiretroviral therapy (ART) adherence strategies for HIV+ adolescents and young adults (AYA) are needed to prevent HIV-related morbidity, mortality, and onward transmission. In the Adherence Connection for Counseling, Education, and Support (ACCESS) pilot, an exploratory sequential mixed-methods design was used to develop and test a peer-led, mobile health (mHealth) cognitive behavioral ART adherence intervention. HIV+ AYA (ages 16–29 years) with unsuppressed plasma HIV RNA (HIV viral load) were eligible for this five-session intervention directed to improving ART adherence and HIV viral load. A total of 78 peer-led remote videoconferencing sessions (via WebEx) were delivered to 16 participants. High completion rates (97.5%) and client satisfaction scores (mean = 29.13 of 32; SD = 2.45) were observed. Self-reported ART adherence improved (32% increase in doses taken; 95th CI 11.2–53.3) with an annualized average rate of 47.5% (0.28 log10) reduction in HIV viral load. We established proof of concept for the ACCESS peer-led, mHealth cognitive behavioral ART adherence intervention, with promising adherence and virologic outcome data.

Abstract

Students at universities are experiencing food insecurity, which may be associated with health behaviors. In a pilot study to build a survey that assesses food insecurity and health behaviors among undergraduates, we distributed the survey before (Wave 1; fall 2019) and during (Wave 2; summer 2020) COVID-19. During Wave 1, 41% of students reported food insecurity and 61% met criteria for poor sleep. In Wave 2, 26% reported food insecurity and 49% met criteria for poor sleep. Students experiencing food insecurity were more likely to report poor sleep. This survey will inform recruitment and design of a scaled-up multi-campus study. (100/100 words).

Abstract

Research in aging has significantly advanced; scientists are now able to identify interventions that slow the biologic aging processes (i.e., the “hallmarks of aging”), thus delaying the onset and progression of multiple diseases, including oral conditions. Presentations given during the 3-part session “Geroscience: Aging and Oral Health Research,” held during the 2023 American Association for Dental, Oral, and Craniofacial Research meeting, are summarized in this publication. Speakers’ topics spanned the translational research spectrum. Session 1 provided an overview of the geroscience and health span (disease-free and functional health throughout life) concepts. The common molecular mechanisms between oral cancer and aging were discussed, and research was presented that showed periodontal microflora as a potential factor in Alzheimer’s disease progression. Session 2 focused on behavioral and social science aspects of aging and their oral health significance. The keynote provided evidence that loneliness and isolation can have major health effects. These social conditions, along with poor oral health, tooth loss, and cognitive decline, could potentially affect healthy eating ability and systemic health in older adults. Research could help elucidate the directions and pathways connecting these seemingly disparate conditions. Session 3 focused on the delivery of oral care in different settings and the many barriers to access care faced by older adults. Research is needed to identify and implement effective technology and strategies to improve access to dental care, including new delivery and financing mechanisms, workforce models, interprofessional provider education and practice, and use of big data from medical–dental integration of electronic health records. Research to improve the “oral health span,” reduce oral health disparities, and increase health equity must be tackled at all levels from biologic pathways to social determinants of health and health policies.

Abstract

Objectives: Studies on the interdependence of couples’ health behaviors and subsequent cognitive outcomes remain limited. Methods: Longitudinal data from the China Health and Retirement Longitudinal Study (2011–2018) were used (N = 1869 heterosexual couples). Latent class analysis identified the dyadic pattern of health behaviors in 2011 (i.e., alcohol consumption, smoking, and physical inactivity). Stratified Cox models examined the association of latent classes with risk of developing memory-related disorders in 2013–2018. Results: Three classes were identified: class 1 (21.25%, only husband smoke, and both active), class 2 (47.55%, both inactive, neither drink nor smoke), and class 3 (31.20%, both drink and smoke, and both active). Couples’ sedentary lifestyle was associated with an increased risk of memory-related disorders among both husbands and wives. Conclusion: Couples were moderately concordant in their physical activity but weakly in smoking and drinking. Couple-based interventions, especially promoting physical activity, may reduce cognitive aging among middle-aged and older Chinese couples.